San Francisco Burden of Disease & Injury Study:
Determinants of Health
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Determinants [note: this informated may be dated and is here for historical referrence ]

The web of causation of disease and injury is complex, but each component part can be mapped, its contribution to disease burden can be estimated, and prevention strategies can be informed by a systematic analysis of what has been evaluated elsewhere. Ultimately, this will be a repository of evidence that can be used to guide prevention planning in San Francisco.

The determinants explored below are organized into four categories, based upon a model developed by Murray & Lopez (see figure below) (See also, Background on the identification of determinants for the San Francisco Burden of Disease & Injury Study). Interventions can (and need to be) applied at every level. Resources from the Disease Control Priorities Project (many of which are appropriate for developed economies) will be particularly helpful in developing this work in progress.

Social/Environmental/ Political Determinants [sources: The Solid Facts: Social Determinants of Health (pdf), some key articles, plus several hours of deliberation by the workgroup, which identified key areas of focus] Behavioral/Individual Determinants [sources: Attribution Matrix and McGinnis & Foege (or, more recently, Mokdad et al) plus deliberation by the workgroup.

Clinical/Physiological Determinants [clinical conditions -- some of these also appear as DALYs, since Disability Adjusted Life Years includes morbidity]

Health Outcomes [premature mortality and DALYs, plus major public health programs, plus several that were identified by the workgroup]
(listing not in rank order)

physical environment (transport)

social inequality (low SES)

social exclusion (institutional racism)

social support (lack of social connectedness)



illicit drugs

motor vehicle traffic

physical inactivity

poor diet


unsafe sex


heart disease

high blood pressure

diabetes (type 2)

high cholesterol






substance use problems

ischemic heart disease*
lung cancer

breast cancer
poisonings (overdose)

traffic accidents
drug overdose
hypertensive heart disease
colorectal cancer
violence (homicide)
alcohol use disorder
colorectal cancer
cirrhosis of liver
sexually transmitted disease
low birth weight
infant mortality


* leading health outcomes (cardiovascular disease is main cause of premature mortality; depression is leading cause of DALYs)

By clicking on any of the above determinants (to the extent that they have links) you can see that how that determinant fits within the causal web for San Francisco. We need to make a final decision on which determinants we will depict here...we're missing some of those from Healthy People 2010). [Each determinant has its own "home page" ... see physical inactivity as an example.] This upstream/downstream grouping of Determinants is based on a broad conception of health that is presented in the introduction to the 2002 Overview of Health in SF.

Figure 1. Simplified causal web linking exposures and outcomes. For a discussion of the issues involved in quantification of risks within this framework, see Murray et al.


Updated May 1, 2010

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